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The Disappearing Family Doctor – Is It a Bad Thing?

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By DAVIS LIU, MD

The New York Times recently published an article titled the Family Can’t Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.Continue reading…

A Modest Proposal: What If All Specialty Procedures Were Coded with 4 CPT Codes?

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By PAUL FISCHER, MD

In a recent Wall Street Journal article, Barbara Levy, Chairwoman of the Relative Value Scale Update Committee (RUC), commented on the American Medical Association’s (AMA’s) decision to have minimal primary care participation on the RUC, saying the committee is an “expert panel” and not meant to be representative.  Since the committee is made up of 27 specialists, one family doc, and a pediatrician, the AMA apparently believes it requires little in the way of primary care expertise but lots of experts from every minute surgical specialty.

This is, of course, reflected in the AMA’s coding system.  Most of primary care is condensed into four Evaluation and Management (E/M) codes: a “focused” encounter, an “expanded” encounter, a “detailed” encounter, and a “comprehensive” encounter (99212-99215).  It does not matter whether the problem is a cold or an acute myocardial infarction.  It does not matter if you worked with just the patient or the entire family spanning three generations.  It does not matter if the problem was simple and common (eg, essential hypertension) or rare and complex (eg, pheochromocytoma).  It does not matter whether you completed everything in a single visit or spent hours fighting with an insurance company for payment.  And it does not matter whether you dealt with a couple of well-established problems or a dozen new ones.  It is clear that the AMA has little expertise in this area.  What is amazing is that they think they have enough!

In contrast, there are 400 pages in the CPT book to help proceduralists get maximum pay for their work.  In general, procedure coding follows a scheme based on the part of the body, the number of times you repeat a procedure, how fancy the equipment is, and how many different names you can come up with to do the same work (eg, vein ablation, injection, sclerosing, ligation, interruption, excision, or stripping).  This is obviously a boon for many physicians’ income.Continue reading…

Comparing Hospitals on Safety, Quality and Cost

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By MERRILL GOOZNER

The Sunlight Foundation today gave us a fascinating first peak at the hospital safety data from the Centers for Medicare and Medicaid Services, which was finally convinced to release the information after years of stonewalling by the American Hospital Association. For the first time, the public can compare less-than-stellar performance at competing local hospitals on key indicators like catheter or urinary tract infections or bed sores.

As their story points out, the data only cover about 60 percent of hospitals since many states, like Maryland, failed to cooperate with the voluntary CMS program. They also caution that any comparison of the raw numbers must take into account the numerous confounding variables that can make one hospital look more slipshod in its practices than another. Some hospitals take in many more older and poorer patients, who are more likely to have multiple chronic conditions that make them prone to complications during their hospital stays.

Yet as Arthur Levin of the Center for Medical Consumers, a New York-based advocacy group, pointed out, “”I think it’s fair (to release the data) as long as everybody agrees on what the limitations are, and what the caveats are. There are those who say this data isn’t ready for prime time and public review. If we waited for perfection, we wouldn’t have anything out there.”Continue reading…

Of Zebras, Rare Diseases, and Google

By RICHARD REECE, MD

When you hear hoof beats behind you, don’t expect to see a zebra.

Medical aphorism on the rarity of rare diseases

A rare or “orphan” disease affects fewer than 200,000 people in the United States. There are more than 6,000 rare disorders that, taken together, affect approximately 25 million Americans.

National Organization for Rare Disorders (NORD)

I have been asked to speak before a group of seniors about rare diseases. The thought fills me with trepidation. I am not an expert on rare diseases. There are so many of them. I fear being misquoted or misunderstood. I worry about malpractice implications, even though I am no longer in practice.

Nevertheless I am going to give the seniors my two cents worth, which is about what my opinion is worth. The temptation is irresistible. “To talk of diseases,” as Sir William Osler said, “is a sort of Arabian Nights entertainment.”Continue reading…

Up Next? Oral Health

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By MICHAEL PAINTER, MD

“Can you imagine a time when we fully incorporate mental and dental health into our thinking about health?  What is it about problems above the neck that seems to exclude them so often from policy about health care?”

That’s what Institute of Medicine President Harvey Fineberg asked in 2009.  On April 8th the IOM released a new consensus committee report, “Advancing Oral Health in America”. That committee’s 2011 response to Dr. Fineberg was essentially—“not this time—change starts here.”  I had the great privilege of participating on that committee along with 14 others from a variety of backgrounds and expertise.  Certainly, we were daunted by the enormity of the nation’s oral health challenge but also hopeful that there are, in fact, tools and approaches that could begin to make a difference.

The IOM convened this committee based on a 2009 HRSA request for recommendations on a potential HHS oral health initiative.  The committee deliberated for almost a year while the long and contentious health care reform debate reverberated.  The specific charge for this committee was relatively narrow:  to provide strategic recommendations to HHS, specifically, regarding a department-wide oral health initiative.  Nevertheless, the national health care reform debate only served to highlight the concurrent need for reform in both oral health as well as health care, overall.

And there were a few ghosts in the mix, so to speak—namely past reports, statements, actions, initiatives in oral health—good faith efforts all—juxtaposed against the harsh fact that the problems remain.  More than 10 years prior, the surgeon general issued a landmark report entitled, “Oral Health in America”.  It described the poor state of oral health as a “silent epidemic”.  Unfortunately and in spite of that warning, that epidemic remained altogether too silent.  In fact, arguably, nothing fundamentally has changed in those 10 years.  Entirely preventable oral diseases remain prevalent.  Oral health is part and parcel of overall health care—but the professions treat them as distinct and separate.  Vulnerable groups continue to suffer from disparate oral health outcomes.  Continue reading…

Who Gets Autism?

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By NEUROSKEPTIC

The paper is from Leonard et al and it’s published in PLoS ONE, so it’s open access if you want to take a peek. The authors used a database system in the state of Western Australia which allowed them to find out what happened to all of the babies born between 1984 and 1999 who were still alive as of 2005. There were 400,000 of them.

The records included information on children diagnosed with either an autism spectrum disorder (ASD), intellectual disability aka mental retardation (ID), or both. They decided to only look at singleton births i.e. not twins or triplets.

In total, 1,179 of the kids had a diagnosis of ASD. That’s 0.3% or about 1 in 350, much lower than more recent estimates, but these more recent studies used very different methods. Just over 60% of these also had ID, which corresponds well to previous estimates.

There were about 4,500 cases of ID without ASD in the sample, a rate of just over 1%; the great majority of these (90%) had mild-to-moderate ID. They excluded an additional 800 kids with ID associated with a “known biomedical condition” like Down’s Syndrome.

So what did they find? Well, a whole bunch, and it’s all interesting. Bullet point time.

  • Between 1984 to 1999, rates of ID without ASD fell and rates of ASD rose, although there was a curious sudden fall in the rates of ASD without ID just before the end of the study. In 1984, “mild-moderate ID” without autism was by far the most common diagnosis, with 10 times the rate of anything else. By 1999, it was exactly level with ASD+ID, and ASD without ID was close behind. Here’s the graph; note the logarithmic scale:

Continue reading…

Interview with Andy Cohen, CEO, Caring.com

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A couple of weeks back Andy Cohen, CEO and Founder of Caring.com stopped by Health 2.0’s offices to give us an update on the site. Having established itself as a go-to site for caregivers needing to figure out what to do when a loved one needs help, Caring has now branched out to develop assessment tools and communities. In this video interview you’ll get to hear and see a bit about that, and get more information about the company’s plans to be the “Babycenter” for the other end of life.

Feds on the Web: Medicare relaunches caregiver site

I’ve been impressed by the efforts of CMS and others in the Federal government to develop helpful websites. Medicare has just relaunched its Caregivers website. It’s got a nice variety of stories, links and resources–including links to multiple partners offering support communities and other help. While the Physician Compare site had problems (and is a much more complex effort), I thought that Healthcare.gov was a good start to the complex world of finding health insurance, and the Health Indicators Warehouse is another good start at releasing masses of data in a usable format (FD Health 2.0’s Technology Guide is linked to as part of the site). Everything here can and will be improved, and much of this will be built on by the private sector–and that’s the way it should be. But given the scorn poured upon government, lets recognize the strides made.

The Kübler-Ross Model of EHR Adoption

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By MARGALIT GUR-ARIE

For over a hundred years the paper chart has been a trusted partner and best friend to many physicians and nurses. The paper chart was born the day a new patient walked into the office, a pristine, crisp and neatly color-coded folder, with just the right markings in carefully shaped calligraphy on its covers. As the years went by, the paper chart grew in size, acquired meaning and wisdom, and like most of us, became a bit tattered around the edges and heftier in the middle. It felt good to hold the elderly paper chart in your hands and its voluminous physical presence inspired confidence and trust. The paper chart is dead. In some places the paper chart’s pages are still turning slowly, but we all know its long, productive life has come to an end and someone should pull the plug and call it. Or do we?

In 1969 Elisabeth Kübler-Ross proposed a 5 stage model for typical grieving behavior. The various reactions from the clinical community to the apparent demise of the paper chart exhibit almost textbook adherence to the Kübler-Ross model, with each clinician advancing through the five stages of grief at his/her own pace*.

Denial – This is a joke. These people don’t understand medicine and this entire Obamacare thing will soon go away and we’ll return to normalcy. My practice is doing just fine on paper and my patients get all this fancy medical home care right here and always had. They actually get better care. Besides, I have patients to see and I am too busy to tinker with these fads that come and go every five years or so.Continue reading…

There Aren’t Enough Rich People To Pay For Medicare And Medicaid

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By ROBERT LASZEWSKI

I hear more and more of my progressive friends arguing, in the context of deficit reduction, that we should be raising taxes before getting aggressive about reducing the cost of Medicare and Medicaid — as well as Social Security.

To a point, I agree.

This country is in such a hole that it is senseless to deny that at least some new taxes will be needed to pay for all of the nation’s bailouts and accumulated debts.

For instance, progressives would like to end the $1 trillion cost over ten years of the Bush tax cuts for those making more than $250,000 a year.

I also believe that ending those tax cuts is necessary.

But if you’re looking to better understand the budget policy choices we face, I highly recommend the March 2011 Congressional Budget Office study, “Reducing the Deficit: Spending and Revenue Options.” The CBO prices out about all of the budget options.Continue reading…

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